For decades, the treatment of Anorexia Nervosa was guided by myths and assumptions such as:
- Dysfunctional family dynamics are the cause of anorexia nervosa
- We can’t help her until she wants to get better
- Therapy has to address the “root cause” of the illness before she will start eating
More recently, these myths have been disproven. It’s no surprise, then, that older methods of treatment based around these myths were not very effective. A generation ago, many people who developed anorexia nervosa as teenagers suffered from the illness for years or even decades.
Fortunately, this is no longer the case. Thanks to more recent scientific research, we now know that there is no particular “family dynamic” or type of parenting that causes anorexia nervosa. We know that the inability to recognize the problem, and the desire to remain sick, are brain-based symptoms of anorexia nervosa. Perhaps most importantly, we now know that nutritional restoration and weight gain must happen as soon as possible, whether the teenager likes it or not, in order to give the patient a better chance of full recovery.
New Principles to Guide Treatment
There’s a new type of treatment called Family-Based Treatment (FBT), also known as the Maudsley Approach, which was developed at the Maudsley Hospital in London and brought to the United States around 2000. FBT is based on a set of principles that are, in many ways, diametrically opposed to the myths that guided older treatment approaches. FBT is grounded in the following principles:
- The cause of anorexia nervosa is unknown, but parents are not to blame.
- Parents are the experts on their children, and parents have unique strengths and resources to help their child recover.
- Full nutrition is the essential first step in recovery from anorexia nervosa.
- Parents can – and must – require their malnourished child to eat the types and amounts of food that he or she needs to recover.
In FBT, parents are the leaders of their child’s treatment team, and a therapist works as a consultant to them. With the support and guidance of a clinician who specializes in eating disorders, parents are coached in how to create a home environment that is conducive to recovery.
A Three-Phased Approach
FBT involves three phases:
- Phase I focuses exclusively on re-feeding and weight restoration. The therapist weighs the patient openly at each session. Steady weight gain (e.g., 1-3 pounds per week) is expected. The therapist gives suggestions and advice to help the parents support their child at mealtimes, increase his or her food intake, and interrupt eating disorder behaviors. Parents are empowered and encouraged to create a united front against the anorexia nervosa and to find an approach that works best for their particular child.
- Phase II begins when the teenager has returned to a healthy weight. The goal of this phase is to help the parents gradually hand back control over eating to their teenager as he or she demonstrates readiness to handle this responsibility while maintaining a healthy weight.
- Phase III begins when the patient is able to eat with an age-appropriate level of independence and is no longer engaging in eating disorder behaviors. The goal of Phase III is to help the adolescent establish a healthy identity and resume a normal teenage life. At this point, any issues that stand in the way of normal teenage functioning, such as depression, anxiety, social difficulties, or body dysmorphia, are identified and addressed.
Typically, a course of FBT involves approximately 20 – 25 sessions over the course of 12 months. Treatment duration may be shorter or longer, depending on the severity of the child’s illness and other individual differences.
Better Recovery Rates
Scientific research has demonstrated adolescents who receive FBT are more likely to recover – and stay recovered – than those who receive individual therapy or residential treatment. In fact, FBT is the only evidence-based treatment for anorexia nervosa at this time.
Why is FBT so much more effective than other approaches? We don’t know for sure, but recent research has shed light on some of the factors that contribute to FBT’s success:
- FBT enhances parental self-efficacy, or the parent’s confidence in their ability to help their child recover. Parental self-efficacy, in turn, is associated with patient weight gain.
- FBT – more so than other approaches – focuses on prompt weight restoration, and weight restoration is a catalyst for broader recovery. Once a teenager is no longer semi-starved, many anorexia nervosa symptoms decrease or disappear. A well-nourished, healthy teen is better able to do the cognitive and emotional work of recovery.
- Teenagers benefit from the support and guidance of their parents, especially when they are ill. FBT allows teens to remain at home with their natural support system and empowers parents to be intimately involved in their child’s recovery.
- The structure of FBT allows effective treatment to begin without requiring the adolescent to have any insight, motivation, or desire to recover.
- Placing parents in charge of food decisions, and having them provide daily meal support, allows the adolescent to override the powerful urge to restrict.
- FBT, more so than adolescent-focused treatment, is associated with improvements in several domains of family functioning, perhaps because of the active parental involvement inherent to the FBT process. Healthy family functioning, in turn, creates an environment more conducive to recovery for the patient.
Why Family-Based Treatment?
The internet has allowed people all over the world to access information about treatment for anorexia nervosa with the click of a button. It is becoming increasingly common for concerned parents to do extensive research on anorexia nervosa and decide for themselves on a treatment approach that best suits their teenager and their family. Some fortunate families are referred to FBT as soon as their child is diagnosed. Other families find FBT through their own desperate searches after other treatment approaches have failed.
For many parents of teens with anorexia nervosa, FBT makes intuitive sense and reaffirms their basic parental instinct to feed their starving child. Parents love their child more, are more invested in their child, and are more knowledgeable about their child than professionals could ever be.
Other forms of treatment, which remove the adolescent from her parents’ care or exclude her parents from treatment decisions, may implicitly send the message that parents are guilty of causing the illness, or at least are unnecessary in aiding recovery. Parents may feel ashamed, guilty, and powerless to help their child, and teens may feel angry, hurt, abandoned, or mistrustful of their families.
Family-Based Treatment also has the advantage of being efficient and cost-effective. Residential and day-treatment programs can cost hundreds or thousands of dollars per day. Traditional outpatient treatment, which typically involves multiple professionals from different disciplines, entails several appointments per week and can become quite costly and time-consuming. In contrast, FBT minimizes professional involvement and thus keeps costs low. Typically, families who are undergoing FBT attend only one session per week with a therapist, plus periodic medical appointments with a pediatrician. A recent Australian study found that FBT was significantly more cost-effective than adolescent-focused treatment.
Not a Magic Bullet
Like all forms of treatment, Family-Based Treatment has its limitations. Each patient is unique, each family is unique, and what works wonders for one family may be terribly ineffective for another. For some patients, FBT may not be effective, and for other families, implementing it is not an option. FBT is not recommended for families in which the parents are physically or sexually abusive, or for families in which parents are actively abusing drugs or alcohol. Some parents may not have the time or financial resources to implement daily meal support due to other family or work-related responsibilities. FBT places a tremendous burden on parents, and parents often feel isolated, exhausted, anxious, or depressed as they are desperately helping their children recover. Some teenagers with severe anorexia nervosa may be unable to restore weight even with intensive family support. And some patients with anorexia nervosa have major medical or psychiatric comorbidities, such as suicide attempts, that render home-based treatment unsafe.
Fortunately, the situations described above are the exception rather than the rule, and most families are able to make FBT work for them when they have good professional support. Many parents who are helping their children recover through FBT benefit tremendously from the support and guidance of other parents through parent advocacy organizations such as FEAST: Families Empowered and Supporting Treatment for Eating Disorders. FBT can be very effective even in single-parent families, blended families, and families affected by divorce or other major stressors. From newly diagnosed adolescents to those who have not improved with other types of treatment, FBT brings new hope for full recovery.
Young Adults With Anorexia: Not Too Old For Family Therapy
Helping Teens with Eating Disorders Get Treatment
Preventing Caregiver Burnout
What Is Anorexia Nervosa
Higher-Weight (Atypical) Anorexia Nervosa
To learn more about an adolescent’s experience of FBT, listen to this podcast.
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Ciao, A.C., Accurso, E.C., Fitzsimmons-Craft, E.E., Lock, J., LeGrange, D.L. (2015). Family functioning in two treatments for adolescent anorexia nervosa. International Journal of Eating Disorders, 48, 81-90.
Khanh-Dao Le, L., Barendregt, J.J., Hay, P., Sawyer, S.M., Hughes, E.K., & Mihalopoulos, C. (2017). The modeled cost-effectiveness of family-based and adolescent-focused treatment for anorexia nervosa. The International Journal of Eating Disorders, 50, 1356-1366.
Le Grange, D., Lock, J.D., Loeb, K., & Nichols, D. (2009). Academy for Eating Disorders Position Paper: The Role of Families in Eating Disorders.
Lock, J.D., Le Grange, D., Agras, S., Moye, A., Bryson, S.W., Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of General Psychiatry, 67, 1025-1032.
Sadeh-Sharvit, S., Arnow, K.D., Osipov, L., Lock, J.D., Jo, B., Pajarito, S., Brandt, H., Dodge, E., Halmi, K.A., Johnson, C., Kaye, W., Wilfey, D., Agras, S.W. (2018). International Journal of Eating Disorders, 51, 275-280.
About the Author
Dr. Sarah Ravin is a licensed psychologist in private practice near Miami specializing in Family-Based Treatment for adolescent eating disorders. Dr. Ravin writes an award-winning blog on eating disorders and related topics in psychology and serves as a professional advisor for FEAST: Families Empowered and Supporting Treatment for Eating Disorders.